Sensory Changes

The Individualized-Sensory Enhancement of the Elderly (I-SEE) program was developed to tailor nursing interventions to the type and level of sensory impairment experienced by the older adult (Cacchione, 2007). Originally developed to address hearing- and visually impaired older adults, the I-SEE can logically be extended to address sensory impairment in smell, taste, and peripheral sensation. There are three levels to the I-SEE program: nursing assessments, nursing actions, and nursing referrals.

NURSING SENSORY ASSESSMENTS

A.  History

  1.  Ask questions about changes in hearing, vision, sense of smell, and taste, as well as any numbness and tingling in extremities.
  2. Review medications that may be exacerbating the sensory problem, such as anticholinergic medications, antibiotics, aminoglycosides, and high-dose aspirin.
  3. Determine whether symptoms occurred suddenly or gradually.
  4. Clarify whether symptoms are unilateral or bilateral.
  5. Inquire whether the individual has had any prior treatment for sensory conditions.
  6. Ascertain whether sensory conditions interfere with daily function.
  7. Ask about ability to drive; both daytime and nighttime driving can be impacted by visual impairment as well as hearing and the peripheral nervous system.
  8. Determine interest in receiving treatment for these conditions.

B.  For each positive symptom reported, gather more information by asking about the following: character, associated symptoms, radiation, location, intensity, and duration, as well as what makes it better, what medications the individual has tried for these symptoms, and what makes it worse. These questions can be easily remembered by using the acronym CAR LID BMW. Answers to these questions provide a better understanding of the individual’s concerns.

PHYSICAL EXAM FOR ALL SYSTEMS

A.  Inspect the external structures of the eyes and ears; examine the ear canal for cerumen using an otoscope.

B.  Check visual acuity with a near vision screener and distance acuity measure and contrast sensitivity.

C.  Perform whisper test to assess rough hearing. If available in your setting, use a handheld audioscope to assess up to 40-dB hearing. If a greater range of hearing testing is needed, use a portable audiometer with noise-reduction earphones—a referral to audiology may be indicated.

D.  Assess the nares; determine whether they are patent using the otoscope.

E.  Inspect the mouth and tongue for any obvious lesions, odors, or deviations from normal.

F.   Perform a neurosensory exam of the extremities, including a monofilament test.

G.  Complete a monofilament test on all diabetics. This test quantifies the level of sensory impairment in the feet of patients with diabetes.

H.  Assess vibratory sense of the extremities with a 128-Hz tuning fork and proprioception.

IV. NURSING ACTIONS AND REFERRALS

A.  Vision

  1. Avoid disruption in the management of chronic eye conditions by obtaining past history and ensuring continuation of ongoing regimens such as eye drops for glaucoma.
  2. Notify the primary care provider of any acute change in vision.
  3. Encourage the use of good lighting in patient rooms. Avoid glare whenever possible.
  4. Encourage the use of the patient’s eyeglasses. Have family provide lighted magnification if needed. (These are the large magnifiers with a light attached; available for purchase on a sliding scale at low-vision centers.)
  5. Add contrast to the fixtures and electronics in the room if light switches blend into the wall or faucets blend into the sink. Other low-contrast items in the environment include remote controls, television sets, and radios.
  6. Encourage annual eye exams either with an optometrist or ophthalmologist.
  7. Schedule an annual dilated exam for patients with diabetes and hypertension by an ophthalmologist.
  8. Written materials should be provided in at least 14- to 16-point high-contrast fonts with generous white space to improve visual tracking.
  9. Encourage use of adaptive equipment.
  10. Reinforce referrals for low-vision intervention.

B.  Hearing

  1. Assess for cerumen impactions. Request cerumen softening drops followed by cerumen removal or ear, nose, and throat consultation.
  2. Get the person’s attention and face him or her before speaking to assist the individual with lip reading; if female, consider wearing red lipstick to increase the contrast of your lips, a common compensatory mechanism for older adults.
  3. Have at least one pocket amplifier on the nursing unit to use with hard-of-hearing individuals.
  4. Do not shout at people with hearing impairments, but rather use lower tones of your voice.
  5. Provide written instructions (use thick, black marker if person is also visually impaired).
  6. Encourage use and ensure appropriate care for hearing aids: remove batteries at night; use brush provided to gently clean the tubes to reduce wax accumulation. Before sending bed linens or clothing to the laundry, determine whether the patient’s hearing aid is in his or her ear or in its designated location (bedside table or medication cart).
  7. Notify the primary care provider of any sudden change in hearing, including tinnitus or sensations of fullness.
  8. Referral to audiologist and/or ENT as indicated (e.g., complicated cerumen impactions, new-onset tinnitus, or vertigo).
  9. Encourage use of adaptive equipment, particularly in social settings.

C.  Taste and smell

  1. Take all complaints of inability or decreased ability to smell or taste seriously. Do not pass them off to medications or poor dentition.
  2. Notify the primary care provider of an abrupt change in taste or smell.
  3. ENT referral for evaluation for change in smell or taste.
  4. Patient teaching should focus on safety issues with odors of gas and spoiled food.
  5. Educate seniors to have smoke and carbon monoxide detectors in their homes, date all food in the refrigerator, and evaluate food with methods other than sense of smell and taste.

D.  Peripheral sensation

  1. Educate every older adult to examine his or her feet daily, as well as to look inside his or her shoes before putting them on each day.
  2. Educate the older adult to always wear shoes or protective slippers when he or she is ambulating to avoid unintentional injury to his or her feet.
  3. The individual should be instructed to inform his or her primary provider of any lesions, calluses, or red areas.
  4. Extremities should be kept clean and thoroughly dry before applying lotion.
  5. Encourage the individual to bring in footwear for evaluation by the advanced practice nurse if he or she has concerns about safety. Most medical supply companies carry diabetic healing shoes that have wide toe boxes and Velcro straps that can be purchased for less than $50.
  6. Refer diabetics to facilities with certified diabetes educators and foot care specialists.
  7. Implement fall precautions and initiate referral to physical therapy for all diabetics with peripheral neuropathy.
  8. Refer all older adults with decreased sensation or circulation to a podiatrist or foot care specialist for ongoing foot care.
  9. Encourage a diet rich in thiamine and B12.

EXPECTED OUTCOMES

A.  Baseline visual acuity and hearing acuity for all older patients will be performed before discharge from the hospital, and on admission to home care or nursing home.

B.  Fall precautions should be in place for all older patients with sensory impairments. Older adults should avoid falls and injuries to extremities if they have decreased sensation of lower extremities.

C.  Accidental exposure to toxins, either in the air or in food because of decreased sense of smell or taste, should be avoided.

FOLLOW-UP MONITORING

A.  Annual vision assessment: Medicaid in most states will pay for a new pair of eyeglasses every 2 years.

B.  When vision is worse than 20/125, individuals should be referred to a low-vision specialist to provide training in the use of visual assistive devices.

C.  Given that hearing can change significantly over time, an audiological evaluation for hearing-impaired older adults every 2 years is important. Primary care annual visits should ask about hearing impairment, complete an audioscope evaluation, and refer to audiology for positive screens for hearing loss. Some states will pay through Medicaid for one hearing aid under limited conditions. Hearing aids have been shown to be better accepted if older adults receive them when they start having difficulty with word finding with background noise. Encouragement and hearing rehabilitation are needed to improve the consistent use of hearing aids. Audiologists can help train older adults and their families in the use of hearing aids.

D.  When abrupt changes in smell or taste are reported, a referral to a dentist or ENT is indicated.

E.  Long-term adjustments must be made in the home when smell and taste are affected. First, food should be dated and discarded after 48 hours to avoid accidentally eating spoiled food. Smoke and carbon monoxide detectors must be present.

F.   When xerostomia (severe dry mouth) is found, a referral to a dentist is indicated.

G.  Older adults with decreased peripheral sensation should be referred to neurology for an accurate diagnosis and followed regularly by a podiatrist or foot care specialist.

INTERPROFESSIONAL CARE OF SENSORY CHANGES

A.  Care of the aging senses is an interprofessional endeavor. Nurses who frequently have the most contact with clients can take the lead in assessing and screening older adults for decreased sensory function.

B.  Once these deficits are identified, it is important to take the appropriate steps and identify the resources available to the older adult.

C.  Occupational therapists, low-vision specialists, audiologists, nutritionists, otolaryngologists, and neurologists are just some of the interprofessionals who may be part of the team caring for the sensory-impaired older adult.

D.  Good communication among disciplines is essential to assist the older adult in benefitting from each specialist.

ABBREVIATIONS

ENT            Ear, nose, and throat

I-SEE          Individualized-Sensory Enhancement of the Elderly

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Updated: November 2020

Boltz PhD, RN, GNP-BC, FGSA, FAAN, M., Capezuti PhD, RN, FAAN, E., Zwicker DrNP, APRN, BC, D., & Fulmer PhD, RN, FAAN, T. T. (2020). Evidence-Based Geriatric Nursing Protocols for Best Practice (6th ed.). Springer Publishing. Retrieved November 4, 2020, from https://www.springerpub.com/evidence-based-geriatric-nursing-protocols-for-best-practice-9780826188144.html#description

REFERENCES

Cacchione, P. Z. (2007). Nursing care of older adults with age-related vision loss. In S. Crocker Houde (Ed.), Vision loss in older adults: Nursing assessment and care management (pp. 131–148). New York, NY: Springer Publishing Company. Evidence Level VI.